Provider Demographics
NPI: | 1891157046 |
---|---|
Name: | FERNANDES, GRENVILLE RIO-JOHN (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | GRENVILLE |
Middle Name: | RIO-JOHN |
Last Name: | FERNANDES |
Suffix: | |
Gender: | M |
Credentials: | MD |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 6330 E 75TH ST STE 110 |
Mailing Address - Street 2: | |
Mailing Address - City: | INDIANAPOLIS |
Mailing Address - State: | IN |
Mailing Address - Zip Code: | 46250-2717 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 317-588-7130 |
Mailing Address - Fax: | 317-588-7133 |
Practice Address - Street 1: | 6330 E 75TH ST STE 110 |
Practice Address - Street 2: | |
Practice Address - City: | INDIANAPOLIS |
Practice Address - State: | IN |
Practice Address - Zip Code: | 46250-2717 |
Practice Address - Country: | US |
Practice Address - Phone: | 317-588-7130 |
Practice Address - Fax: | 317-588-7133 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2016-03-27 |
Last Update Date: | 2020-12-08 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
IN | 01084046A | 208100000X |
390200000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 390200000X | Student, Health Care | Student in an Organized Health Care Education/Training Program | |
Yes | 208100000X | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
IN | 300039070 | Medicaid |